What are the requirements for minors to access Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) prevention, including parental involvement?

Minors' Access to HIV PrEP: Parental Consent Requirements

Minors can access PrEP without parental consent in most U.S. jurisdictions, but the legal landscape varies significantly by state, and providers must verify their specific state laws before prescribing.

Legal Framework for Minor Consent

The ability of minors to consent to PrEP without parental involvement depends on state-specific statutes regarding STI/HIV services:

• 34 states either expressly allow minors to consent to HIV services OR allow consent to STI/communicable disease services and classify HIV as an STI or communicable disease 1
• Only 8 jurisdictions explicitly allow minors to consent to preventive or prophylactic services for STIs 1
• 17 jurisdictions allow minors to consent to STI testing and treatment but lack express HIV provisions and do not classify HIV as an STI or communicable disease, creating legal ambiguity for PrEP 1
• No state expressly prohibits minors' access to PrEP or other HIV prevention methods 1

Critical Distinction: PrEP vs. PEP

The legal clarity differs between prevention modalities:

• Post-exposure prophylaxis (PEP) after HIV exposure is generally treated as HIV treatment/testing, where parental consent can be provided when the minor has "limited or no capacity to consent," though assessment of HIV status should not barrier initiating PEP 2
• Pre-exposure prophylaxis (PrEP) exists in a legal gray zone because it is preventive rather than diagnostic or therapeutic, making it unclear whether existing minor consent statutes apply 1

FDA Approval and Clinical Guidance

PrEP is FDA-approved for adolescents:

• TDF/FTC (tenofovir disoproxil fumarate/emtricitabine) approved in 2018 for adolescents weighing ≥77 lb (35 kg) 3
• TAF/FTC (tenofovir alafenamide/emtricitabine) approved in 2019 for adolescents weighing ≥77 lb (35 kg), excluding those at risk through receptive vaginal sex 3
• Cabotegravir long-acting injectable also approved for adolescents 4

Practical Clinical Approach

Providers should follow this algorithm:

1. Verify state law first: Check whether your state allows minors to consent to STI prevention services or classifies HIV services broadly enough to include PrEP 1, 3

2. Partner with the adolescent: Recognize the adolescent's autonomy to the extent allowable by law, making PrEP decisions collaboratively with the patient 3

3. Include parents when safe and reasonable: Involve parents in the conversation about PrEP when it is safe to do so and does not compromise the adolescent's willingness to seek care 3

4. Do not delay care: If parental involvement would create a barrier to accessing needed HIV prevention, and state law permits minor consent, proceed without parental involvement 3

Key Barriers Unique to Minors

Clinicians report specific concerns about prescribing PrEP to minors:

• Confidentiality concerns and legal uncertainty about minor consent without parental involvement 5
• Concerns about minors' capacity to understand risks/benefits of PrEP 5
• Off-label use concerns (though this is now resolved with FDA approval) 5
• Bone health concerns given potential impact on bone mineral density accrual during adolescence 5
• Cost and insurance issues, particularly when parental insurance involvement would breach confidentiality 5

Common Pitfalls to Avoid

Do not assume parental consent is required simply because the patient is a minor—this varies by state and may unnecessarily barrier access to life-saving prevention 1, 3

Do not conflate PrEP with HIV treatment laws—while many states allow minors to consent to HIV treatment, only 8 explicitly extend this to preventive services 1

Do not delay PrEP initiation while attempting to involve parents if the adolescent is at substantial HIV risk and state law permits minor consent 3

Adherence Considerations

Adolescents face unique adherence challenges:

• PrEP adherence declined over time in adolescent studies, mirroring patterns in adults 3
• More frequent clinical follow-up and supportive interactions are recommended to promote medication adherence in adolescents 3
• Technology-based interventions, provider education, navigation support, and multiple access options can increase PrEP uptake and adherence 4